History

Chief Complaint

A useful way to open the clinical evaluation is to ask a question, such as “What can I help you with today?” This allows the patient to describe the problem in their own words without interruption. Patients with symptomatic glenohumeral arthritis will often complain of pain, stiffness, crepitation on movement, loss of function, difficulty sleeping, and discomfort with changes in barometric pressure. Glenohumeral arthritic pain is commonly felt over the posterior aspect of the glenohumeral joint in contrast to pain from cervical radiculopathy that is commonly felt in the area of the trapezius. It is important to document the circumstances surrounding the onset of the problem, its pattern of progression over time, and its response to prior medical and surgical treatment.

Because it is important to get a “snapshot” of the condition of the shoulder at the time of initial presentation, we ask all our new patients to characterize their shoulder comfort and function using the Simple Shoulder Test (SST) ( Box 16-1 ), a practical, efficient, sensitive, and extensively validated tool that we developed based on the chief complaints of patients presenting to us with shoulder arthritis. The major functional deficits for the common types of glenohumeral arthritis include difficulty with sleeping comfortably on the affected side, washing the back of the opposite shoulder, placing eight pounds on a shelf, and throwing overhand ( Fig. 16-9 ; Table 16-1 ).

Box 16-1

Simple Shoulder Test

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  Is your shoulder comfortable with your arm at rest by your side?

  
  
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  Does your shoulder allow you to sleep comfortably?

  
  
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  Can you reach the small of your back to tuck in your shirt with your hand?

  
  
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  Can you place your hand behind your head with the elbow straight out to the side?

  
  
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  Can you place a coin on a shelf at the level of your shoulder without bending your elbow?

  
  
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  Can you lift 1 lb (a full pint container) to the level of your shoulder without bending your elbow?

  
  
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  Can you lift 8 lb (a full gallon container) to the level of the top of your head without bending your elbow?

  
  
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  Can you carry 20 lb (a bag of potatoes) at your side with the affected extremity?

  
  
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  Do you think you can toss a softball underhand 10 yards with the affected extremity?

  
  
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  Do you think you can throw a softball overhand 20 yards with the affected extremity?

  
  
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  Can you wash the back of your opposite shoulder with the affected extremity?

  
  
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  Does your shoulder allow you to work full time at your regular job?

Percentage of 3128 patients with primary degenerative joint disease of the shoulder able to perform each of the 12 functions of the Simple Shoulder Test.

TABLE 16-1

Percentage of Patients Able to Perform Functions of the Simple Shoulder Test at the Time of Initial Evaluation, According to Type of Glenohumeral Arthritis

Function	DJD	SDJD	RA	CTA	CA	AVN
Sleep comfortably	12	13	18	8	0	29
Arm comfortable at side	67	36	61	33	65	79
Wash back of shoulder	13	20	13	0	18	7
Hand behind head	35	38	26	21	35	50
Tuck in shirt	32	33	39	38	29	50
8 lb on shelf	19	16	3	0	18	7
1 lb on shelf	54	36	26	21	53	50
Coin on shelf	59	44	29	29	53	64
Throw overhand	7	9	3	4	0	0
Do usual work	39	44	21	17	41	21
Throw underhand	53	44	13	42	29	21
Carry 20 lb	62	62	21	33	41	29

 

AVN, avascular necrosis; CA, capsulorrhaphy arthropathy; CTA, cuff tear arthropathy; DJD, degenerative joint disease; RA, rheumatoid arthritis; SDJD, secondary degenerative joint disease.

As a patient-reported assessment, SST serves as the baseline for documenting the presenting status of the shoulder and tracking its response to treatment over time, and it removes concern over variability related to different observers. Importantly, this assessment tool does not require the patient to return to the office, but rather can be submitted by mail, email, or online. Without any substantial investment of time or money, this practical method allows surgeons to establish for themselves the time to recovery and the duration of the functional benefit of different procedures and share these results with prospective patients. Perhaps even more importantly, monitoring changes in SST after surgery enables the surgeon to identify individual arthroplasty procedures that were not successful in restoring comfort and function for the patient, and to learn from these “with a view to preventing similar failures in the future,” as recommended by Codman.

The second important self-assessment tool is the Short Form-36 Health Survey (SF-36), which enables patients to document their overall health status. The SF-36 scales of emotional role function, mental health, and social function are more closely correlated with pain and functional impairment than the “objective” measures of the severity of the disease. For patients with osteoarthritis presenting for shoulder arthroplasty, the SF-36 scores are inversely correlated with the number of comorbidities. The greatest compromise in the self-assessed overall health status of patients with glenohumeral arthritis is found in the SF-36 domains of physical role function and overall comfort ( Table 16-2 ). For patients with primary or secondary degenerative joint disease or cuff tear arthropathy (CTA), scores for the other SF-36 parameters (such as vitality and overall health) are relatively close to those of population-based age- and sex-matched controls. In contrast, the health status of patients with rheumatoid arthritis, capsulorrhaphy arthropathy, or avascular necrosis is poorer than that of controls of the same age and sex. The overall well-being of the patient, including preoperative physical function, general health, social function, and mental health, has been shown to be strongly correlated with the quality of the outcome after shoulder arthroplasty. The recognition of the importance of the overall condition of the patient in influencing the outcome of treatment recalls the quote often attributed to Sir William Osler: “It is much more important to know what sort of a patient has the disease than what sort of a disease the patient has.” SF-36 provides a convenient and standardized way of knowing “what sort of a patient has the disease.”

TABLE 16-2

Self-Assessed Health Status of Patients, Revealed by SF-36, According to the Type of Glenohumeral Arthritis *

SF-36 Parameter	DJD	SDJD	RA	CTA	CA	AVN
Physical role function	44	33	23	30	39	28
Comfort	54	47	34	39	40	47
Physical function	78	73	38	81	62	50
Emotional role function	83	76	58	100	64	40
Social function	84	73	63	81	71	62
Vitality	86	83	44	81	65	60
Mental health	92	90	87	97	76	84
General health	100	93	65	100	71	63

 

AVN, avascular necrosis; CA, capsulorrhaphy arthropathy; CTA, cuff tear arthropathy; DJD, degenerative joint disease; RA, rheumatoid arthritis; SDJD, secondary degenerative joint disease; SF-36, Short Form-36 Health Survey.

* Data presented as the mean percentage of the value for an age- and sex-matched control population.

Physical Examination

Perhaps the most important part of the physical examination looks at the overall person: is the individual happy or depressed, healthy or chronically ill, fit or frail, well nourished or malnourished, actively engaged or passive? Who accompanied the patient to the visit: spouse, friend, caregiver, caseworker, or lawyer? Does the patient smell of cigarettes or alcohol, or have pinpoint pupils suggestive of narcotic use? Does the patient use a cane or crutch, and if so, in which hand? Is the patient steady or unsteady on his or her feet? Can the patient get up on the examination table unassisted? Does he or she use the involved arm to slip off a coat or to talk or to shake hands?

Inspection of the shoulder requires it to be exposed by appropriate disrobing so that the examiner can evaluate the health of the skin over the shoulder, in the axilla, and down the arm, as well as the presence and location of previous skin incisions and the manner in which they healed. Is the arterial, venous, and lymphatic circulation of the limb intact, or has the patient had prior lymph node dissections and lymphedema? Are the deltoid, cuff, and periscapular muscles of normal or diminished size compared with the opposite side? Are there signs of inflammation (warmth, tenderness, and erythema)? Is there swelling suggestive of infection, CTA, or Charcot arthropathy?

After the inspection, it is useful to start the physical examination with a “no-touch” opening: “Can you show me the movements that are the biggest problem for you?” These patient-identified limitations allow initial consideration about which treatment may be of benefit. Next, we ask the patient to demonstrate the ability to actively abduct, flex, and rotate the shoulder as well as reach across the body and up the back, first with the normal shoulder and then with the symptomatic one. In a patient-friendly way this provides an initial broad assessment of the function of the shoulder and the degree of discomfort associated with motion. After asking permission to physically examine the shoulder, we palpate it, seeking evidence of effusion, tenderness, or glenohumeral instability, as well as subacromial, glenohumeral, scapulothoracic crepitance, or rotator cuff and subscapularis defects ( Figs. 16-10 to 16-12 ).

Palpation of cuff defects. Defects in the tendinous cuff can often be palpated through the overlying skin and deltoid.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:283.)

Palpation of supraspinatus defects. The accessibility of the supraspinatus tendon for palpation can be enhanced by extending the arm.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:283.)

A defect in the superior subscapularis tendon insertion may be palpable at the anterior shoulder.

We then proceed with the formal evaluation of shoulder mobility, including the assessment of forward elevation ( Fig. 16-13 ), abduction ( Fig. 16-14 ), external rotation at the side ( Fig. 16-15 ), external rotation in abduction ( Fig. 16-16 ), internal rotation up the back ( Fig. 16-17 ), internal rotation in abduction ( Fig. 16-18 ), and cross-body adduction ( Fig. 16-19 ). These tests evaluate the range of motion of the humerus relative to the thorax. A more specific assessment of the range of glenohumeral motion can be obtained if the examiner uses one hand to stabilize the scapula while establishing flexion and extension and internal and external rotation of the humerus, relative to the scapula, with the other hand. It is useful to show the patient and family members the contrast between the motion of the affected shoulder and that of the contralateral normal or less affected shoulder. Whereas most arthritic shoulders show reduced range of motion, those with subscapularis defects from injury or prior surgery may show an increased range of external rotation.

Limited humeral forward elevation relative to the thorax.

Limited humeral abduction.

Limited humeral external rotation with the arm adducted at the side.

Limited humeral external rotation with the arm in the 90-degree abducted position.

Limited humeral internal rotation behind the back as measured by the level of the thumb position relative to the level of spine.

Limited humeral internal rotation with the arm in the 90-degree abducted position.

Limited cross-body adduction as measured by the distance between the elbow antecubital crease and the opposite shoulder.

Arthritic shoulders may be unstable. Shoulders with degenerative joint disease or capsulorrhaphy arthropathy may demonstrate posterior humeral translation as the arm is raised in the plane of the scapula ( Fig. 16-20 ) or when it is actively moved from 90 degrees of abduction to 90 degrees of flexion ( Fig. 16-21 ). Shoulders with anterior glenoid deficiency may demonstrate anterior instability as the arm is moved from flexion to extension. Shoulders with cuff deficiency may demonstrate upwards displacement of the humeral head with active contraction of the deltoid, referred to as “anterosuperior escape” ( Figs. 16-22 to 16-25 ). Shoulders with distorted bony anatomy, cuff deficiency, or deltoid deficiency may have inferior instability.

Posterior humeral head subluxation as the arm moves from adduction at the side ( A ) to abduction in the scapular plane ( B ), referred to as “scaption.”

Posterior humeral head subluxation ( red arrow ) as the arm actively moves from 90 degrees of abduction ( A ) to 90 degrees of flexion ( B ).

Anterosuperior escape.

Rotator cuff tear arthropathy with anterior instability.

Rotator cuff tear arthropathy with severe acromial erosion that predisposes to acromial fracture.

In shoulders with rotator cuff deficiency the humeral head demonstrates superior displacement with active contraction of the deltoid ( bottom left ). If the coracoacromial arch is also impaired, anterior displacement from beneath the acromion may occur, referred to as “anterosuperior escape” ( bottom right ).

Shoulder strength is examined by manually assessing the isometric force that the patient can generate with the anterior, lateral, and posterior deltoid, as well as with the supraspinatus ( Fig. 16-26 ), infraspinatus ( Fig. 16-27 ), and subscapularis ( Fig. 16-28 ) muscles. Examination of the function of suprascapular, long thoracic, axillary, musculocutaneous, median, radial, and ulnar nerves is important both for identifying possible neurologic contributions to the patient’s symptoms as well as establishing the integrity of these nerves before surgical intervention.

The supraspinatus is tested by positioning the arm in 90 degrees of abduction in the plane of the scapula and in internal rotation; this puts the supraspinatus tendon on top of the humeral head. The patient holds this position while the examiner attempts to adduct the arm.

The infraspinatus is tested by positioning the humerus with the elbow at the side and the forearm pointing straight ahead. The patient holds this position while the examiner attempts to push the arm into internal rotation.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:287.)

The subscapularis is tested by having the patient press the hand in toward the stomach, keeping the elbow in the plane of the body. The patient holds this position while the examiner attempts to pull the hand away from the stomach (red dotted arrow).

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:287.)

Finally, examination of the neck may reveal evidence of cervical spondylopathy that may be contributing to the patient’s symptoms, or restriction of the range of neck motion that would require special attention at the time of surgery. In patients with rheumatoid arthritis it is important to determine neck stability as well as the patient’s ability to open their mouth to a degree that would allow anesthetic intubation. In all patients the health of the teeth and gums is particularly important if surgery is being considered.

Radiographic Evaluation

The purpose of imaging of the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient ( Fig. 16-29 ). Although CT scans may offer a few degrees of increased precision in the measurement of glenoid version, we are not convinced that this precision improves the quality of the surgery or the clinical outcome. Standardized plain films are almost always sufficient to garner the information needed and, as described below, there is information that can be gathered from properly taken plain films that cannot be obtained from CT scans. Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome, so we always take time to ensure that our radiograph technologists know what we are seeking in the images.

Three-dimensional reconstructions can reveal fine details of the shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty.

The first key view is the anteroposterior (AP) in the plane of the scapula taken so that the x-ray beam passes through the glenohumeral joint ( Fig. 16-30 ). This view shows the superoinferior position of the humeral head relative to the glenoid, the presence of osteophytes on the humeral head and glenoid, narrowing of the joint space, the degree of medial displacement of the humerus in relation to the lateral acromial line ( Fig. 16-31 ), the quality of the humeral and glenoid bone, the presence of loose bodies, and whether there is humeral head collapse or deformity.

Anteroposterior radiograph in the plane of the scapula taken 30 degrees medial to the lateral of body’s sagittal plane such that the x-ray beam passes through the glenohumeral joint. It is most easily taken by positioning the patient’s scapula flat against the cassette (asterisk) and then passing the beam at right angles to the film, aiming at the coracoid process.

A, Normal humeral lateral offset with the greater tuberosity lateral to the lateral acromial line (red line). B, Loss of humeral lateral offset due to medial joint erosion in glenohumeral arthritis. C, Improved humeral lateral offset following an anatomic total shoulder arthroplasty.

The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula ( Fig. 16-32 ) and oriented so that both the spinoglenoid notch and the scapular neck are visible. This view shows a different perspective of the humeral anatomy, the amount of glenoid bone, the shape of the glenoid, its version in relation to the plane of the scapula, and the relationship of the humeral head to the glenoid fossa. We refer to this view as the “truth view” because it demonstrates the glenohumeral relationships in the functional position of elevation. This is in contrast to CT scans, which have the disadvantage of being taken with the arm in the adducted position ( Fig. 16-33 ). Unfortunately, many of the “axillary views” sent to us for consultation are taken without standardization, making it impossible to determine the important features of the glenohumeral joint ( Fig. 16-34 ).

Axillary view taken with the arm in the functional position of elevation in the plane of the scapula. This is referred to as the axillary “truth view.”

Computed tomographic scan taken with the arm at the side.

A nonstandardized axillary view from which it is difficult to determine the glenohumeral pathoanatomy.

When taken properly, the standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, relative positions of the humeral head and the glenoid, presence of osteophytes ( Fig. 16-35 ), degree of osteopenia, and extent of bony deformity and erosion.

A, A large “goat’s beard” osteophyte shown on the anteroposterior view. B, A medially eroded glenoid seen on the axillary view.

Since arthritis usually involves the central aspect of the humeral head ( Figs. 16-36 and 16-37 ; see Fig. 16-7 ), joint space narrowing is most evident on the truth view as opposed to images made with the arm at the side. Of even greater importance is the ability of the axillary truth view to show posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side ( Figs. 16-38 to 16-44 ). The degree of posterior subluxation can be measured as (1) the position of the center of the humeral head in relation to the plane of the scapula ( Fig. 16-45 ), (2) the position of the center of the humeral head in relation to the glenoid face ( Fig. 16-46 ), or (3) the point of contact of the humeral articular surface on the glenoid articular surface ( Figs. 16-47 and 16-48 ). We prefer the last of these because this point of contact reflects the degree of centering of the net humeral joint reaction force on the glenoid (see Fig. 16-47 ). It is the malcentering of this joint reaction force that leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components. The standardized axillary view also enables the surgeon to see the shape of the glenoid surface. Three main surface types have been described : concentric wear (type A) (see Fig. 16-35 ; Fig. 16-49 ), eccentric posterior wear (type B) ( Fig. 16-50 ), and dysplastic (type C) ( Fig. 16-51 ). In practice there are so many intermediate types of glenoid pathoanatomy that rigorous categorization into a few distinct classes is difficult (see Fig. 16-50 ; Figs. 16-52 to 16-58 ). An important aspect of glenoid pathology is the amount of the glenoid that is involved in the pathologic concavity, known as the “neoglenoid” ( Fig. 16-59 ). Finally, the standardized axillary view enables measurement of the degree of glenoid retroversion in relation to the body of the scapula ( Figs. 16-60 and 16-61 ). Thus, on the standardized axillary view, the surgeon can usually determine the major important characteristics of glenohumeral arthritic pathoanatomy: the amount of joint space narrowing, degree of retroversion, degree of posterior subluxation with the arm in a functional position, shape of the glenoid, percentage of the glenoid involved in the pathologic concavity, and angle of retroversion (see Figs. 16-45 to 16-47, and 16-61 ). Because of their low cost and freedom from metal artifacts, standardized axillary views provide a practical and reliable way to document the postoperative anatomy sequentially over time and to compare it to the anatomy before surgery.

Secondary degenerative joint disease with a central humeral defect from contact with suture anchors. A, Anteroposterior radiograph showing minimal joint space narrowing. B, Axillary view showing minimal joint space narrowing. C, Intraoperative image showing substantial central defect.

The “Friar Tuck” pattern of central baldness commonly seen in primary degenerative joint disease, with remaining articular cartilage at the periphery. This central loss of articular cartilage is only evident on radiographic images taken with the arm in abduction, a position that places the bald spot in contact with the glenoid.

Functional decentering revealed by the “truth view” that was managed with a ream and run arthroplasty using an anteriorly offset humeral component. A, Anteroposterior radiograph showing degenerative changes. B, Axillary view showing functional decentering of the humeral head on the glenoid. C, Anteroposterior view showing reconstruction with the ream and run procedure. D, Axillary view showing improved centering achieved with an anteriorly eccentric humeral head component.

Functional decentering in the absence of substantial glenoid retroversion. A, The anteroposterior view suggests minimal pathology. B, The truth view shows decentering of the humeral head, as indicated by a posterior contact point of the humeral head on the glenoid face.

The axillary truth view reveals pathology without computed tomography. A, Anteroposterior view showing loss of glenohumeral joint space. B, Axillary view showing severe posterior subluxation in a biconcave glenoid.

Functional decentering. A, Anteroposterior view showing an arthritic glenohumeral joint. B, Axillary view showing posterior humeral head subluxation into a biconcave glenoid.

Functional decentering. A, Anteroposterior view showing an arthritic glenohumeral joint. B, Axillary view showing posterior humeral head subluxation into a biconcave glenoid.

Functional decentering. A, Anteroposterior view showing an arthritic glenohumeral joint. B, Axillary view showing posterior humeral head subluxation into a biconcave glenoid.

Functional decentering. A, Anteroposterior view showing an arthritic glenohumeral joint. B, Axillary view showing posterior humeral head subluxation into a biconcave glenoid.

Measure of humeral posterior subluxation as the distance (SD) from the humeral head center (HC) relative to the scapular plane (red dotted line) through the mid glenoid, that is, glenoid center (GC), which is point midway between the anterior (A) and posterior (P) glenoid rim. The humeral head center is determined from the best circle for the humeral head curvature (circular black dotted line).

Measure of humeral posterior subluxation as the distance (SD) from the humeral head center (HC) relative to the mid-glenoid axis (red line). The glenoid plane (black line) is the line between the anterior (A) and posterior (P) glenoid rim. The glenoid center (GC) is the midpoint of the glenoid plane. The mid-glenoid axis (red line) is a line perpendicular to the glenoid plane through the GC. Posterior humeral subluxation is calculated as SD divided by the glenoid width (GW).

Measure of humeral posterior subluxation as determined by the point of contact of the humeral articular surface on the glenoid articular surface. The point of contact is characterized as the ratio of the distance from the anterior lip of the glenoid to the center of glenohumeral contact (red arrow) divided by the distance between the anterior and posterior lips of the glenoid (black arrow).

Measurements of the pathoanatomy of the arthritic glenohumeral joint. S is the axis of the scapular body. G is the line connecting the anterior and posterior lips of the glenoid. C is the distance between the anterior lip of the glenoid and the center of the contact area between the humeral head and the glenoid. The angle between G and S reflects the glenoid version. The ratio of C to G reflects the position of the center of contact point on the face of the glenoid; a centered contact point has a ratio of 0.5.

Axillary view showing an A2 glenoid.

Axillary view showing a major biconcavity with a relatively small amount of posterior subluxation.

Glenoid dysplasia. A, Anteroposterior radiograph showing glenoid deformity. B, Magnetic resonance image showing failure of formation of the posterior glenoid bone.

Axillary view showing a small biconcavity illustrating the high degree of variability in glenoid pathoanatomy.

Axillary view of the “bad arthritic triad”: a biconcave glenoid, glenoid retroversion, and posterior subluxation of the humeral head on the glenoid.

Axillary view of a mildly biconcave glenoid, with minimal glenoid retroversion but substantial posterior subluxation of the humeral head on the glenoid.

Axillary view showing a small biconcavity illustrating the high degree of variability in glenoid pathoanatomy.

Posterior subluxation with minimal glenoid biconcavity and mild retroversion.

Axillary view showing a small biconcavity illustrating the high degree of variability in glenoid pathoanatomy.

Various intermediate types of glenoid pathology depend on the extent of medial glenoid erosion, posterior humeral subluxation, biconcave glenoid morphology, and glenoid retroversion.

An important aspect of glenoid pathology is the amount of glenoid fossa that is involved in the pathologic concavity, known as the “neoglenoid.”

Degree of glenoid retroversion relative to the scapular plane. The glenoid plane (red line) is presented by the line through the anterior and posterior glenoid rim. The scapular plane (dotted line) is presented by the line parallel to the scapular body. Glenoid version is the angle between the scapular plane and the glenoid plane.

A, The important characteristics of glenohumeral pathoanatomy can be quantified on the standardized axillary view. B, Glenoid version is the angle between the axis of the scapular body (S) and the line connecting the anterior and posterior lips of the glenoid (G). C, The degree of centering is indicated by the ratio between the distance between the anterior lip and the point of glenohumeral contact (C) and the distance between anterior and posterior lips of the glenoid (G). A well-centered articulation has a ratio of 0.5.

A third view, the templating view, is obtained when humeral arthroplasty is being considered. This view is an anteroposterior (AP) view of the humerus taken with the arm in 30 degrees of external rotation relative to the x-ray beam, with a magnification marker added ( Fig. 16-62 ). This view places the humeral neck in maximal profile and allows the comparison of potential humeral prostheses with the proximal humeral anatomy ( Fig. 16-63 ). In templating, it is important to recognize that the humeral canal is not cylindrical; the mediolateral dimension is usually wider than the anteroposterior dimension and so the AP view may overestimate the size of the stem that will fit the diaphysis ( Fig. 16-64 ). The templating view is also useful for determining whether sufficient osteoporosis is present to merit special consideration at the time of arthroplasty ( Fig. 16-65 ).

A and B, The humeral templating view is obtained by having the flexed forearm externally rotated 30 degrees with respect to the x-ray beam. C, The humeral templating view shows the humeral shaft with the humeral head and neck in maximal profile. A calibrated marker helps correct for magnification in templating.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:11.)

Templating view. The templating view enables the surgeon to preview the procedure and estimate the required component size and fit.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:513.)

The varying shape and orientation of the humeral canal cross sections from proximal to distal make it impossible to fit the endosteal surface with a defined shape of prosthetic body (left). There is also wide variety between humeral medullary canals that are more cylindrical or more funnel-shaped (right). A tapered stem would not fit well in a cylindrical canal, and a cylindrical stem would not fit well in a funnel-shaped canal.

Impaction bone grafting for an osteopenic humerus. A, Anteroposterior radiograph showing very thin bone. B, Humeral prosthesis secured with impaction grafting without reaming to a press-fit, bone ingrowth, or cement.

Advanced imaging may be useful for unusual cases where the anatomy is distorted by prior injury or surgery, when there is concern about the amount of bone available for reconstruction, or when the standardized plain radiographs cannot be obtained. In the great majority of cases, however, the extra cost and radiation dose of the CT scan can be avoided through the use of standardized plain films. We can learn what we need to know about the status of the rotator cuff from physical examination and plain radiographs, so shoulder MRIs are rarely needed unless indicated to exclude avascular necrosis or tumor. However, MRI of the neck may be useful in evaluating patients suspected of having cervical radiculopathy, myelopathy, stenosis, or a syrinx.

Laboratory Evaluation

We do not usually obtain blood or joint fluid laboratory tests in the assessment of the arthritic shoulder. There are two exceptions: cases of suspected inflammatory or septic arthritis (where tests, such as the rheumatoid factor, sedimentation rate, C-reactive protein, and antinuclear antigen may be useful) and suspected malnutrition (where tests, such as a complete blood count, hemoglobin A1C, metabolic chemistry panel, iron binding capacity, transferrin, albumin, and prealbumin may be useful in addition to assessment of the body mass index).

Degenerative Joint Disease

Degenerative joint disease is also known as osteoarthritis, osteoarthrosis, or wear and tear arthritis. The pathogenesis of this condition results from the age-related loss of the ability of articular cartilage to sustain itself against seemingly minor mechanical imbalances and years of use. Degenerative joint disease typically affects healthy and active individuals. In our practice most patients with degenerative glenohumeral joint disease are of Northern European rather than Asian, Southern European, Hispanic, or African ancestry. The disease results in progressive loss of the glenoid cartilage and subchondral bone, typically in one of two patterns: concentric medial loss, which is more characteristic of female shoulders and shoulders with inflammatory arthritis; or eccentric posterior loss (with the articular cartilage often left intact anteriorly), which is more characteristic of male shoulders and shoulders with degenerative joint disease or capsulorrhaphy arthropathy ( Fig. 16-66 ). The concern with the eccentric wear pattern is that the diminished articular contact area results in increased force per unit area leading to increased posterior wear, which in turn results in even less contact area ( Fig. 16-67 ). The cartilage of the humeral head is eroded in a so-called “Friar Tuck” pattern: central baldness often surrounded by a rim of remaining cartilage and osteophytes (see Figs. 16-7 and 16-37 ). The bone underlying the joint surfaces is usually sclerotic, but degenerative cysts can occur in the humeral head or glenoid. When severe, glenoid cysts may jeopardize the fixation of prosthetic glenoid components ( Fig. 16-68 ).

Degenerative arthritis. A, Anteroposterior view in the plane of the scapula. B, Axillary view showing posterior erosion typical of degenerative arthritis and capsulorrhaphy arthropathy. The humeral head is displaced posterior to the glenoid centerline (dotted line).

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:425.)

Contact pressure. Loss of the articular cartilage from the humeral head and glenoid results in the loss of the uniform distribution of the humeral joint reaction force over the face of the glenoid. A, Normal load transfer. B, Load transfer after cartilage loss results in a locally large joint pressure and a steep pressure gradient between the loaded and unloaded glenoid bone.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: WB Saunders; 2004:424.)

Cyst formation within the glenoid may compromise glenoid component fixation, requiring the use of bone graft or cement. A, Anteroposterior radiograph. B, Computed tomographic scan.

In its early stages degenerative glenohumeral joint disease may be visible only on the truth view radiograph (see Fig. 16-38 ). Later, it is typical for osteophytes to surround the anterior, inferior, and posterior aspects of the humeral head and the inferior and posterior glenoid; as a result, the humeral and glenoid articular surfaces may take on a flattened configuration that blocks rotation ( Fig. 16-69 ). We refer to the commonly seen inferior humeral osteophyte as the “goat’s beard” (see Fig. 16-35 ; Fig. 16-70 ). Loose bodies are often found in the axillary or subscapularis recesses. The pathoanatomy of the arthritic glenoid may include medial erosion, posterior erosion, and retroversion along with varying degrees of posterior humeral subluxation (see Fig. 16-58 ). The triad of glenoid biconcavity, glenoid retroversion, and posterior humeral subluxation—the “bad arthritic triad”—is commonly found together in primary degenerative joint disease. Progressive contracture of the anterior capsule limits external rotation and compounds the tendency of the humeral head to translate posteriorly ( Fig. 16-71 ). Major biceps pathology and substantial rotator cuff defects are uncommon in patients with primary degenerative joint disease. The common clinical course is one of slowly progressive loss of the ability to sleep and to use the shoulder for work and recreation due to shoulder pain and stiffness.

Flattening of the humeral and glenoid articular surfaces. A, Anteroposterior view. B, Axillary view.

The commonly seen inferior humeral osteophyte is referred to as the “goat’s beard” osteophyte (red arrow).

A, Normal capsular laxity allows unrestricted range of motion. B, The capsule may be contracted in degenerative joint disease and must course over osteophytes. C, As the joint approaches the limit of its range, the tension in the capsule and ligaments increases sharply, thereby limiting the range of rotation.

It is of note that young individuals are less likely to have primary glenohumeral osteoarthritis and more likely to have capsulorrhaphy arthropathy, secondary degenerative joint disease, or other more complex forms of arthritis, often a result of injury, prior surgery, or systemic disease. This, along with their greater longevity and increased activity expectations, may help explain the diminished satisfaction and increased rate of arthroplasty complications for younger individuals after shoulder arthroplasty. A number of these important but less straightforward diagnoses are discussed later.

Secondary Degenerative Joint Disease

In contrast to primary degenerative joint disease—that arises spontaneously without a specific cause—secondary degenerative joint disease develops when a prior injury or surgery affects the joint surface, precipitating its degeneration. The presentation and clinical course of each case of secondary arthritis depend on the underlying etiology.

Anchor arthropathy is a type of secondary degenerative joint disease in which the glenohumeral joint surfaces are destroyed by prominent suture anchors used for the repair of superior labral anterior to posterior (SLAP) lesions ( Fig. 16-72 ; see Fig. 16-36 ) or for Bankart repairs ( Figs. 16-73 to 16-75 ). In this condition the suture anchors excoriate the humeral joint surface, which then erodes the glenoid surface. In cases of anchor arthropathy—or with any prior glenohumeral surgery—it is important to be alert to the possibility of infection with Propionibacterium species ( Fig. 16-76 ).

Anchor arthropathy. A, Destruction of the central aspect of the humeral head. B, The cause was prominent suture anchors.

Anchor arthropathy. Metallic suture anchors can be seen in the joint on the anteroposterior ( A ) and axillary ( B ) view.

Anchor arthropathy with excoriation of the articular surface of the humeral head by prominent suture anchors, with secondary loss of the glenoid and humeral articular cartilage. A, Anteroposterior view. B, Axillary view.

Anchor arthropathy caused by placement of suture anchors on the glenoid surfaces. A, Anteroposterior view. B, Axillary view. C, Intraoperative image.

Septic arthritis from Propionibacterium species after a labral repair, with loss of joint space. A, Anteroposterior view. B, Axillary view.

Posttraumatic arthropathy is a condition in which prior injury has damaged the joint surfaces or given rise to malunion with joint incongruity ( Fig. 16-77 ), instability, nonunions, and/or posttraumatic avascular necrosis ( Fig. 16-78 ), without or with problems related to fixation hardware ( Figs. 16-79 to 16-81 ).

Traumatic arthritis with a loss of glenohumeral cartilage developed after malunion of a comminuted proximal humeral fracture. A, Anteroposterior view in the plane of the scapula. B, Axillary view.

Traumatic arthritis with malunion and osteonecrosis of the head segment. A, Radiograph showing collapse of the head segment and a slight malunion of the greater tuberosity relative to the shaft. B, Radiograph showing the collapse of the humeral head segment, but with the tuberosities in reasonable positions on this view. Damage to the glenoid articular surface is underestimated on these projections. Proximal humeral prosthetic replacement or total shoulder arthroplasty might be needed as reconstructive surgery for such situations, depending on the extent of glenoid surface involvement.

Posttraumatic arthritis with humeral head deformity and prominent intra-articular screws. A, Anteroposterior view showing head deformity. B, Axillary view showing head deformity with screw penetration.

Subtuberous nonunion. A, Anteroposterior view. B, Axillary view.

Posttraumatic arthropathy with screws eroding the joint surfaces and the anterior glenoid bone. A and B, Anteroposterior and axillary views with the hardware in place. C and D, anteroposterior and axillary views with the hardware removed.

Anterior or posterior dislocations may be followed by dislocation arthropathy ( Fig. 16-82 ). In unreduced dislocations the humeral head may be indented and worn ( Figs. 16-83 and 16-84 ).The cartilage of the joint surfaces may be replaced by scar tissue, or the subchondral bone may be so weakened by bone atrophy that it collapses after reduction, resulting in an incongruous joint surface ( Fig. 16-85 ).

An elderly man had a 5- to 10-year history of progressively severe shoulder pain and limitation of motion. As an adolescent, he experienced recurrent dislocations of this shoulder; his current arthritis presumably developed subsequent to his recurrent instability.

Arthroplasty for chronic shoulder dislocation. A, Anteroposterior view showing anterior dislocation. B, Axillary view showing posterior humeral and anterior glenoid bone loss. C, Apical oblique view showing posterior humeral and anterior glenoid bone loss. D, CT scan showing posterior humeral and anterior glenoid bone loss. E, Anteroposterior view showing hemiarthroplasty after an iliac crest graft to the anterior glenoid. F, Axillary view showing hemiarthroplasty after an iliac crest graft to the anterior glenoid.

Chronic posterior shoulder dislocation in a 26-year-old man. The injury occurred approximately 1 year prior to obtaining the radiographs. A recent previous anterior approach to the shoulder was ineffective in reducing the dislocation. The shoulder was reduced during a second surgical procedure, but the cartilage of the humeral head was replaced with fibrous tissue. A proximal humeral prosthesis was placed as a part of the reconstructive procedure. A, A 40-degree posterior oblique view illustrating the overlap between the humeral head and the glenoid. B, Clearly illustrated are the posterior dislocation, the slight malunion between the head and shaft fragments, and evidence of fracturing of the lesser tuberosity and healing of this tuberosity to the shaft, although somewhat displaced from the humeral head segment.

This young woman underwent open reduction of a posterior shoulder dislocation that had been unreduced for approximately 2 months. At the time of reduction, the cartilage surfaces were intact, but the humeral head was noted to be somewhat softened. A bone graft was added to the posterior aspect of the shoulder to substitute for an area of glenoid wear. Within the first month after open reduction, it was apparent on the anteroposterior and axillary view that because of its softness, the humeral head had collapsed and traumatic arthritis was developing. A proximal humeral prosthesis was subsequently placed. A, Anteroposterior view. B, Axillary view.

Shoulders with secondary degenerative joint disease often have complex pathology that can challenge surgical management. Each case presents its own particular combination of capsular contracture, scarring, malunion, nonunion, bone loss, bone fragility, nonanatomic location of neurovascular structures, and the presence of hardware from prior procedures.

Capsulorrhaphy Arthropathy

Capsulorrhaphy arthropathy is a specific type of secondary degenerative joint disease in which deterioration of the joint surface is related to a prior repair for recurrent dislocations and is one of the most common causes of severe arthritis in individuals younger than 55 years. It may be caused by overtightening the anterior capsule; when external rotation is limited by a Putti-Platt repair ( Fig. 16-86 ), a Bankart repair, or a Bristow-Latarjet procedure, obligate posterior translation can force the humeral head out of its normal concentric relationship with the glenoid fossa ( Figs. 16-87 and 16-88 ). This chronic posterior humeral subluxation typically erodes the posterior glenoid, and major posterior bone deficiencies can result ( Figs. 16-89 and 16-90 ). Shoulder arthroplasty for capsulorrhaphy arthropathy is associated with high rates of revision surgery and unsatisfactory outcomes because of instability, subscapularis failure, glenoid component failure after total shoulder arthroplasty, and pain from glenoid arthrosis after hemiarthroplasty. The importance of these poor results is heightened as commonly the individuals affected are young.

Putti-Platt repair consisting of shortening of the anterior capsule and subscapularis tendon, limiting humeral external rotation.

Progressive contracture of the anterior capsule limits external rotation and leads to obligate posterior humeral translation, increased force on the posterior glenoid, and eventual posterior glenoid erosion.

Axillary view of capsulorrhaphy arthropathy in which an excessively tight anterior capsular repair is forcing the head of the humerus posteriorly (arrow). This effect is accentuated by forced external rotation. Note also the typical posterior glenoid erosion.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Capsulorrhaphy arthropathy, that is, arthritis after a prior repair for anterior glenohumeral instability. A, Anteroposterior view. B, Axillary view.

Capsulorrhaphy arthropathy. A, Anteroposterior view showing loss of joint space and hardware from a prior repair for anterior instability. B, Axillary view showing glenoid retroversion, a biconcave glenoid, and posterior humeral subluxation.

Rheumatoid and Other Types of Inflammatory Arthritis

Rheumatoid arthritis is a systemic disease with highly variable clinical manifestations. It can appear to be isolated to the glenohumeral joints or it can affect most of the tissues in the body. In rheumatoid arthritis and many other types of inflammatory arthritis, the cartilage is characteristically destroyed evenly across all joint surfaces of both glenohumeral joints. The glenoid is eroded medially ( Fig. 16-91 ) rather than posteriorly, as in degenerative joint disease (see Fig. 16-66 ). The arthritic process erodes not only cartilage but also subchondral bone, rendering it osteopenic and at risk of fracture ( Fig. 16-92 ). Rheumatoid arthritis can be associated with major bone loss and rotator cuff deficiency, even in young individuals ( Fig. 16-93 ). When the onset of the disease occurs during youth, the joint volume may be small ( Fig. 16-94 ) and the humerus curved, with a thin medullary canal ( Fig. 16-95 ). The restoration of comfort and function to the rheumatoid glenohumeral joint is often complicated by concurrent involvement of the rotator cuff * as well as the acromioclavicular, sternoclavicular, elbow, wrist, and hand articulations and the joints of the opposite upper extremity. Arthritis in the lower extremities may demand the use of ambulatory aids and that in the upper extremities may demand wheelchair transfers. Even the skin of an individual with rheumatoid arthritis may be fragile and subject to compromised wound healing. The fragility of a patient with rheumatoid arthritis is often compounded by long-term use of steroids and other antimetabolic medications. The physician should remain aware of the possible coexistence of joint infection as rheumatoid arthritis involves the immune system due to the patient often receiving immunosuppressive medication, and the clinical manifestations of this condition are similar to those of infectious arthritis. Methotrexate may also increase the risk of nerve dysfunction after shoulder arthroplasty.

Inflammatory arthritis. Medial erosion (arrow) typical of inflammatory arthritis. The original contour of the glenoid is shown (dotted line).

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:425.)

A shoulder with rheumatoid arthritis. Sclerosis and osteophytes typical of osteoarthritis are absent. The bone is osteopenic with erosions at the margins of the articular surface. The humeral head is displaced upwards, suggesting cuff deficiency, and the glenoid is eroded medially. A, Anteroposterior view. B, Axillary view.

A shoulder with findings of rheumatoid arthritis more advanced than those shown in Figure 16-92 . A, Anteroposterior view. B, Axillary view.

Severe medial erosion in rheumatoid arthritis. Note that the entire proximal humerus is medial to the lateral acromial line. Normally, the lateral acromial line passes through the lateral humeral articular surface.

Lateral view of the humerus of a patient who experienced the onset of rheumatoid arthritis as a child. The radiograph shows a bend; this was included in the preoperative planning.

* References .

Cuff Tear Arthropathy

CTA is a compound degenerative condition of the shoulder that involves tendon, cartilage, and bone. In this condition, chronic, massive rotator cuff defects are associated with loss of the humeral articular cartilage and superior displacement of the humeral head so that it articulates with the undersurface of the coracoacromial arch. The humeral head becomes “femoralized” by rounding off of the tuberosities, whereas the coracoacromial arch and upper glenoid fossa become “acetabularized” when the humerus sculpts a concentric concavity from these structures ( Figs. 16-96 to 16-106 ).

Cuff tear arthropathy. In cuff tear arthropathy the shoulder takes on a form similar to that of the hip: the greater tuberosity becomes eroded such that the proximal humerus is “femoralized” (dotted lines on the humerus), and the coracoacromial arch and upper glenoid erosion results in their “acetabularization” (dotted lines on the upper glenoid).

Rotator cuff tear arthropathy (CTA) treated with a CTA prosthesis. A, Preoperative anteroposterior radiograph showing superior displacement of the humeral head that has resulted in contact with the acromion as well as the loss of humeral and glenoid articular cartilage and a secondary superior glenoid concavity. The proximal humerus has been “femoralized” and the coracoacromial arch and upper glenoid have been “acetabularized.” B, Preoperative axillary radiograph showing medial but not posterior erosion of the glenoid. C, Intraoperative photo showing measurement of the humeral diameter of curvature. D, Intraoperative photo showing preservation of the clavipectoral fascia coming off the coracoacromial ligament (the “CA+”) to enhance anterosuperior stability. E, Postoperative anteroposterior view after implantation of the CTA prosthesis. Note the congruent fit of the prosthesis in the socket. F, Postoperative axillary view after implantation of the CTA prosthesis.

Rotator cuff tear arthropathy with acetabularization of the coracoacromial arch and upper glenoid.

Rotator cuff tear arthropathy with femoralization of the proximal humerus and actetabularization of the coracoacromial arch and upper glenoid.

Cuff tear arthropathy. Superior medial erosion (dotted red line) typical of cuff tear arthropathy.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures . Philadelphia: Saunders; 2004:426.)

Acromial traction spur. A, Normal position. B, As the humeral head moves upwards, the coracoacromial arch becomes progressively loaded. C, The result is a traction spur in the coracoacromial ligament. Because it lies within the substance of the ligament, this spur does not encroach on the rotator cuff, even though it might look impressive on the radiograph. D, Rotator cuff tear arthroplasty.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures . Philadelphia: Saunders; 2004:280.)

The boutonnière deformity, in which the subscapularis and infraspinatus tendons slide below the center of the humeral head.

(Modified from Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Erosion of the superior glenoid concavity (dotted line and horizontal arrow) compromises the concavity compression stability mechanism and allows upward translation of the humeral head (vertical arrow) when the deltoid contracts.

(Modified from Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Hemiarthroplasty with a laterally extended cuff tear arthropathy (CTA) head. A, CTA prosthesis. B, The installed prosthesis.

Rationale for a laterally extended cuff tear arthropathy (CTA) head. A, Abduction and external rotation are limited due to painful impingement against the uncovered greater tuberosity. Impingement is indicated by the dashed red lines radiating up and to the left. B, The laterally extended CTA head allows a greater arc of motion in abduction and greater external rotation by coverage of the greater tuberosity.

Rotator cuff tear arthropathy. The humeral head is displaced superiorly and medially, eroding into the acromion and upper glenoid. The thinning of the acromion will predispose it to fracture at the time of or after arthroplasty.

In CTA the glenohumeral joint is deprived of several of its major stabilizing factors: the normal cuff muscle force vector compressing the humeral head into the glenoid (see Fig. 16-5 ); the superior lip of the glenoid concavity, which is typically worn away by chronic superior subluxation (see Fig. 16-6 ); and the cuff tendon that is normally interposed between the humeral head and the coracoacromial arch ( Fig. 16-107 ). The superior displacement of the humeral head slackens the deltoid, weakening its ability to flex or abduct the shoulder ( Fig. 16-108 ). As the condition progresses, the coracoacromial arch may become compromised, allowing anterosuperior escape ( Fig. 16-109 ). Prior acromioplasty and section of the coracoacromial ligament further compromise glenohumeral stability and contribute to anterosuperior escape ( Figs. 16-110 and 16-111 ). These consequences of loss of integrity of the coracoacromial arch are reminders of the need to preserve the integrity of the acromion and coracoacromial ligament in all shoulder procedures.

The cuff tendon interposed between the humeral head and the coracoacromial arch stabilizes the head against superiorly directed loads. The graph shows the mean superior humeral displacement (relative to the scapula) as a function of the superior humeral load, comparing displacements under four conditions: intact specimens, after venting the joint to air, after cutting (but not excising) the cuff tendon, and after excising the superior cuff tendon. Note the markedly increased superior displacement after excision of the cuff tendon.

Superior displacement of the humeral head slackens the deltoid so that its ability to flex or abduct the shoulder is weakened.

Patient with long-standing cuff tear arthropathy with anterosuperior escape of the humeral head when active elevation is attempted.

A, Normal shoulder. B, Cuff-deficient shoulder with an intact coracoacromial arch. If the coracoacromial arch remains intact (i.e., not damaged by acromioplasty or coracoacromial arch section), the arch may provide secondary stabilization for the humeral head against the upward pull of the deltoid.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:264.)

Anterosuperior escape of the humeral head. Resection of the coracoacromial ligament and anterior acromioplasty can allow the humeral head of the cuff-deficient shoulder to escape anterosuperiorly.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:265.)

CTA provides several challenges for the surgeon. In the absence of an intact rotator cuff, total shoulder arthroplasty has been shown to have an early failure rate from glenoid loosening through the so called “rocking horse” phenomenon ( Fig. 16-112 ). Standard hemiarthroplasty may provide only partial pain relief and partial improvement in function. Currently, the surgical management of CTA commonly involves either a CTA prosthesis (see Fig. 16-105 ) or a reverse total shoulder arthroplasty ( Fig. 16-113 ).

Total shoulder arthroplasty in the absence of an intact rotator cuff has been shown to result in early glenoid loosening by the “rocking horse” mechanism of the superior migrated humeral component on the superior glenoid component.

In the cuff-deficient shoulder with a compromised coracoacromial arch and subsequent functional anterosuperior escape, the reverse ball-and-socket prosthesis helps provide glenohumeral stability by retensioning the deltoid and moving the center of rotation medially.

Several systems for the classification of the pathoanatomy of CTA have been proposed as guides to treatment. However, we have found the following factors to be even more critical than radiographic classification in determining the treatment: (1) the stability of the humeral head beneath the coracoacromial arch (i.e., the presence or absence of anterosuperior escape) ( Figs. 16-114 and 16-115 ; see also Figs. 16-109 and 16-111 ); (2) the amount of active elevation provided by the deltoid (i.e., the presence or absence of pseudoparalysis, defined as the inability to actively raise the arm to 90 degrees despite a good passive range of motion); (3) the strength of the residual internal and external rotator musculature; (4) the amount and quality of glenoid, humeral, and acromial bone stock available for surgical reconstruction ( Fig. 16-116 ); (5) the patient’s fall risk, which is a particular concern in individuals with Parkinson disease or other problems of balance; (6) the patient’s dependency on the upper extremities for mobility; and (7) the patient’s activity expectations.

Hemiarthroplasty with cuff tear arthropathy. The head component is stable beneath the intact coracoacromial arch.

Anteroposterior radiographs, static and dynamic with fluoroscopy. A, Superior displacement with the arm resting at the side. B, Superior dislocation with the arm under resisted abduction.

Typical radiograph of a progressive cuff tear arthropathy. It shows superior migration of the head with secondary superior glenoid erosion.

Avascular Necrosis

Nontraumatic or primary avascular necrosis of the humeral head may be idiopathic or may be associated with systemic steroids, trauma, dysbaric conditions, renal or other organ transplantation, or systemic illnesses with vasculitis. Other implicated conditions include alcoholism, sickle cell disease, hyperuricemia, Gaucher disease, pancreatitis, familial hyperlipidemia, and lymphoma. Avascular necrosis has also been reported as a result of section of the anterior humeral circumflex artery in open instability surgery.

Avascular necrosis of the humeral head may be seen on plain radiographs or MRI before collapse of the joint surface occurs ( Figs. 16-117 to 16-120 ). Often, a fracture superocentrally through the abnormal subchondral bone is noted ( Fig. 16-121 ). Subsequently, collapse of the subchondral bone can occur, putting the glenoid articular surface at risk for secondary erosion ( Fig. 16-122 ). In end-stage avascular necrosis the irregular humeral head destroys glenoid articular cartilage, resulting in glenohumeral joint disease ( Fig. 16-123 ).

Early avascular necrosis revealed as sclerosis of the superior medial aspect of the humeral head. The humeral head has not collapsed.

Magnetic resonance imaging findings of early avascular necrosis, shown on a sagittal T2-weighted image.

Magnetic resonance imaging findings of early avascular necrosis, shown on a coronal T1-weighted image.

Magnetic resonance imaging findings of early avascular necrosis, shown on a coronal T2-weighted image.

Early collapse of the humeral head in avascular necrosis.

Avascular necrosis with humeral head collapse and secondary destruction of the glenoid articular surface. A, Anteroposterior view. B, Axillary view.

Bilateral avascular necrosis with collapse of the humeral articular surface. A and C, Anteroposterior views. B and D , Axillary views.

Core decompression may be of benefit early in the course of the disease. When the process involves only the humeral head, a humeral hemiarthroplasty is considered, but when the glenoid is involved, a glenohumeral arthroplasty may be needed ( Fig. 16-124 ).

Avascular necrosis with collapse of the humeral head and secondary glenohumeral arthritis. A, Anteroposterior view. B, Axillary view.

Glenohumeral Chondrolysis

Glenohumeral chondrolysis is a condition the etiology of which unfortunately was formerly referred to as being “speculative,” but is now clearly recognized as being most commonly caused by the intra-articular infusion of local anesthetics using a “pain pump.” This condition is particularly a risk after arthroscopic procedures in which suture anchors are placed in the glenoid. Chondrolysis has also been associated with radiofrequency or laser procedures within the joint. The diagnosis is made from a history of pain pump use, the postoperative onset of pain and stiffness, and radiographs showing loss of the joint space without osteophytes ( Figs. 16-125 and 16-126 ). This iatrogenic condition primarily affects young individuals, often leaving them without options other than arthroplasty; even with arthroplasty the prognosis for the recovery of comfort and function is poor. The condition can largely be prevented by avoiding the use of pain pumps and heat energy, which are not necessary for the treatment of shoulder disorders.

Chondrolysis in the right shoulder of a 22-year-old man resulting from the intra-articular infusion of local anesthetics with a pain pump. There was a complete loss of articular cartilage but without the osteophytes or sclerosis typical of osteoarthritis. A, Anteroposterior view. B, Axillary view.

Chondrolysis in the left shoulder of a 24-year-old woman resulting from the intra-articular infusion of local anesthetics with a pain pump. There was a complete loss of articular cartilage but without the osteophytes or sclerosis typical of osteoarthritis. A , Anteroposterior view. B, Axillary view.

Other Types of Arthritis

Neurotropic (Charcot) Arthropathy

Neurotropic (Charcot) arthropathy arises in association with syringomyelia, diabetes, or other causes of joint denervation. The joint and subchondral bone are destroyed because of the loss of the trophic and protective effects of its nerve supply. The individual may have experienced cervical spine trauma in the past, or there may be unrecognized syringomyelia. Other causes include diabetes, leprosy, syphilis, and chronic alcoholism, and it has been suggested that injection of corticosteroids might accelerate the development of this condition. The Charcot joint is characterized by functional limitation and pain, despite the denervation. There is usually significant bone destruction and osseous debris about the joint area ( Figs. 16-127 and 16-128 ). A useful mnemonic for the characteristic features of Charcot arthropathy is given by the three Ds: d enervation, d estruction, and d ebris. This condition can resemble infectious arthritis. The longevity of an arthroplasty performed for Charcot arthropathy may be jeopardized by the lack of a protective nerve supply.

Occasionally, neuropathic arthritis can be confused with more common forms of glenohumeral arthritis. A, Fragmentation of the proximal end of the humerus with bone debris scattered throughout the joint region. B, Bone fragmentation is shown, but in addition, there is a predominantly sclerotic response associated with neuropathic arthritis. The underlying condition in both this patient and the one shown in Fig. 16-126 was syringomyelia of the cervical portion of the spinal cord.

A shoulder with Charcot arthropathy characterized by massive bone destruction. A, Anteroposterior view. B, Axillary view.

Radiation Arthropathy

Radiation, especially for the treatment of breast cancer, can cause a number of shoulder problems: brachial plexopathy, osteonecrosis, secondary malignant bone tumors, and fibrous scarring. Glenohumeral cartilage and subchondral bone are occasionally affected by these changes and can require treatment by prosthetic arthroplasty ( Fig. 16-129 ). A lack of normal soft tissue suppleness, scars from prior surgery, or lymphedema may complicate surgical management.

Cartilage loss, alteration in the shape of subchondral bone with segmental collapse, and a change in bone texture secondary to irradiation performed as part of treatment for breast cancer. Symptoms were quite significant in this elderly woman and were relieved effectively by total shoulder arthroplasty.

Septic Arthritis

Septic arthritis of the shoulder may arise from bacteria in the patient’s dermis, from hematogenous spread from a remote infection, from injections into the joint, or from surgery on the joint itself. Patients with reduced immunologic defenses—from chronic systemic disease or from immunosuppressive medications—are particularly at risk. Radiographs may show bone destruction and instability ( Figs. 16-130 to 16-132 ). Treatment must be directed at resolving the infection before considering arthroplasty for the management of the resulting arthritis.

Septic arthropathy characterized by loss of the joint surface, marginal erosions around the humeral articular surface, rotator cuff destruction, and superior migration of the humerus.

Complete loss of articular cartilage after a coracoid transfer for instability. The shoulder showed multiple positive cultures for Propionibacterium species at revision surgery.

Septic arthritis due to Propionibacterium species after internal fixation of a proximal humeral fracture. A, An internal fixation removed because of the concern for screw penetration into the joint. B, Progressive destruction of the articular surface leading to shoulder hemiarthroplasty, at which time cultures were positive for Propionibacterium species.

Neoplastic Joint Destruction

Neoplastic joint destruction may present insidiously and is often characterized by nonmechanical pain, that is, pain at rest. Alternatively, tumors may present acutely as a pathologic fracture. The diagnosis will depend on knowledge of the patient’s general health; high-quality plain radiographs; and possibly additional imaging modes, such as tomography, CT, bone scanning, or MRI. Identification of the primary lesion in metastatic disease is desirable, but sometimes biopsy of the shoulder lesion is the most direct route when making a diagnosis ( Fig. 16-133 ).

An upper-middle-aged woman with gradual onset of shoulder pain and reduction in movement. The shoulder was more painful with use but was also painful at rest. She had no known systemic illness. A, Involvement of the glenohumeral joint is shown, with some collapse of the humeral head articular surface. More importantly, this radiograph shows destruction of the bone of the glenoid. B, Computed tomographic image showing the bone destruction quite well. A biopsy revealed metastatic thyroid carcinoma.

Miscellaneous Arthropathies

Miscellaneous arthropathies include crystalline arthritis (such as calcium pyrophosphate deposition disease or hydroxyapatite deposition disease), dialysis arthropathy, hemophilic arthropathy, hemochromatosis, synovial chondrometaplasia, alkaptonuria, gouty arthropathy, acromegalic arthropathy, spondyloarthropathy, Milwaukee shoulder, rapidly destructive articular disease ( Fig. 16-134 ), amyloid arthropathy, pseudogout, primary hyperparathyroid arthropathy, psoriatic arthropathy, ulcerative colitis, Crohn disease, Reiter syndrome, pigmented villonodular synovitis, and Lyme arthritis.

Rapid-onset glenohumeral arthritis. A, Anteroposterior view showing findings typical of a chronic cuff tear. B, Axillary view showing slight joint space narrowing. C, Anteroposterior view taken 10 months later with no intercurrent injury or evidence of infection. D, Axillary view. E, Intraoperative image showing destruction of the humeral head.

Communication

Treatment should begin with a dialogue between the surgeon and the patient regarding the diagnosis; the probable natural history of the condition, if untreated; and the potential risks and benefits of the different treatment options. The likely outcomes are discussed in light of the patient’s expectations and the surgeon’s personal experience in treating the patient’s condition. A partnership is formed. Because glenohumeral arthritis is usually insidious in onset and chronic in duration, there is ample opportunity to try nonoperative management. A period of nonoperative treatment offers the patient and surgeon the opportunity to get to know each other better and gives the patient time to learn some of the exercises that will be a part of the postoperative rehabilitation should surgery be elected. Patients may have difficulty recalling the nature of these discussions; thus our practice is to provide illustrated handouts ( Fig. 16-135 ) and our personal email contact information in case questions arise before and throughout the course of treatment.

Educational handouts are useful for informing patients about their disease, the treatment alternatives, and the risks of the different options.

Nonoperative Treatment

Exercises

Glenohumeral joint arthritis is commonly accompanied by stiffness related to contracture and adhesions involving the glenohumeral capsule, the cuff muscles, and the nonarticular humeroscapular motion interface. Disuse or tendon failure can result in weakness of the deltoid and cuff muscles. Instability patterns can also complicate glenohumeral roughness, such as the posterior subluxation characteristic of degenerative joint disease and capsulorrhaphy arthropathy, or the superior subluxation characteristic of CTA.

The mechanics of the shoulder may often be improved by a physician-directed program of gentle range-of-motion and strengthening exercises ( Figs. 16-136 to 16-146 ). Stretching exercises are performed slowly with a full 2-minute hold, allowing time for the muscles to relax and for the tight capsule to be plastically deformed. One of our patients used his electric toothbrush to time his stretches. It is important that vigorous torque and force not be applied in an attempt to regain mobility because of the possibility of causing obligate translation and accelerated wear (see Fig. 16-71 ; Fig. 16-147 ). Strengthening exercises must also be gentle, with the resistance limited to a level that allows at least 20 comfortable repetitions. Activities that apply gentle repetitive traction to the joint, such as the pulley ( Fig. 16-148 ), swimming, latissimus pulls ( Fig. 16-149 ), and rowing ( Fig. 16-150 ), seem to be particularly well tolerated. When forward elevation is weak, gentle progression of the supine press ( Fig. 16-151 ) can be helpful in improving active shoulder motion, even with what seems to be pseudoparalysis. When posterior stability is compromised, gentle external rotator strengthening may help restore the centering of the humeral head ( Fig. 16-152 ).

Stretching in overhead reach, with the opposite arm assisting the movement in place of the therapist.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Stretching in overhead reach with progressive forward leaning used to apply gentle force to the arm.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Stretching in external rotation with the opposite hand used in place of the therapist.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Stretching in external rotation by turning the body away from a fixed object to apply a gentle stretching force.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Stretching in internal rotation with a towel used to apply a gentle stretching force.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Stretching in cross body reach with the opposite arm serving in place of the therapist.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Internal rotation can be strengthened with A, isometrics, B, rubber tubing, or C, free weights.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

External rotation strengthening with A, isometrics, B, rubber tubing, or C, free weights.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

In the press plus the arm is pushed upward until the shoulder blade is lifted off the table or bed.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

In the shoulder shrug exercise the tip of the shoulder is lifted toward the ear while the elbow is held straight.

(From Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II. Practical Evaluation and Management of the Shoulder. Philadelphia: Saunders; 1994.)

Sleeper stretch. A gentle internal rotation force is applied to the arm abducted to 90 degrees.

Forceful torque causes obligate translation leading to accelerated glenoid wear.

Door pulley. If the opposite arm is weak or painful, a pulley is useful in helping the arm in elevation.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:549.)

The lateral pulldown is a useful rehabilitative exercise because it enables movement of the shoulder while a distraction force is applied.

Rowing is a useful rehabilitative exercise because it enables movement of the shoulder while a distraction force is applied.

Incremental press. Integrated forward elevation is developed through a series of exercises that can be progressed in small increments. A, With the patient in the supine position, the two hands are placed close to each other on a light stick and both are pressed upward toward the ceiling. B, The same exercise is repeated with the arms progressively farther apart. C, The arm performs the supine press unassisted. Small amounts of weight are added to the hand until 2 lb can be pressed upward 20 times. D, The patient’s back is elevated slightly while the weight is pressed vertically upward. The amount of elevation is increased when 2 lb can be pressed upward 20 times. E, The progression is continued until the exercise can be performed with the back in a vertical position.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: WB Saunders; 2004:344.)

External rotation strengthening helps center the posterioriorly subluxed humeral head by increasing the anterior displacement force (green arrow). Contraction of the infraspinatus causes a force (black arrow) tangential to the point of contact with the humeral head. The force vector can be resolved into an anterior displacement force on the humeral head (green arrow) and a compression force into the glenoid (blue arrow).

Surgical Treatment

Surgery should be considered for patients with refractory and functionally significant glenohumeral arthritis who are well informed, well motivated, cooperative, sufficiently healthy, and socially supported. Surgical reconstruction offers the potential to optimize soft tissue balance and muscle mechanics as well as the smoothness, size, and shape of the joint surfaces. It should be emphasized that surgery does not “fix” the problem; rather, it provides a basis for the patient to improve the comfort and function of their shoulder through a concerted rehabilitation effort. Although prosthetic arthroplasty is the primary surgical option to be considered when major pain and functional loss result from glenohumeral arthritis, other surgical alternatives may be useful in selected cases.

Arthroscopic

Considerations

Patients sometimes ask, “Why can’t you just use an arthroscope to clean the arthritis out of my shoulder?” We know, however, that because glenohumeral arthritis is a condition in which articular cartilage is lost, the arthritis cannot be “cleaned out.” In most cases simply removing the osteophytes will not improve shoulder comfort and function unless the osteophytes are clearly restricting the range of motion and the joint surfaces are functional. Aspects of glenohumeral arthritis that could potentially be addressed arthroscopically include loose body removal ( Fig. 16-153 ), the release of capsular contracture, and resection of synovitis in cases of inflammatory arthropathy refractory to medical management. Beneficial results have been reported from arthroscopic debridement for glenohumeral arthritis without or with microfracture and without or with glenoid recontouring. However, rigorous evaluation of the outcome is complicated by the inconsistent inclusion of procedures, such as surgery on the subacromial space, acromioclavicular joint, or biceps tendon. It can be concluded from the published results for arthroscopic treatment that this can be successful in early instances of the disease before substantial destruction of the joint has occurred or for osteochondral lesions that are localized. Because such mildly involved shoulders may also improve with nonoperative management, it is important to determine the value of arthroscopic management using carefully controlled studies. The outcome of arthroscopic debridement is worse for shoulders with involvement of the joint surfaces of both the glenoid and the humerus, that is, true glenohumeral arthritis. A recent systematic review found that there was insufficient evidence to support the routine use of arthroscopic debridement for glenohumeral arthritis. Another concluded that isolated arthroscopic debridement and capsular release did not provide sufficient benefit to justify its use in most patients. Microfracture appears to be of little benefit except for small localized defects in either the humeral or the glenoid joint surface. It is important to note that arthroscopic surgery is still surgery, carrying costs and risks. A carefully controlled trial found that arthroscopic surgery for arthritis of the knee was no more effective than sham surgery (which, by the way, resulted in significant clinical improvement, illustrating the need for surgical controls).

Loose body delivered by palpation from the subscapularis recess.

Open

Debridement and Capsular Release

In a small number of cases of early arthritis—especially where there is substantial limitation of motion with relatively preserved joint surfaces—a debridement and capsular release may be considered for patients who wish to avoid a prosthetic arthroplasty, although it should be recognized that subsequent surgery may well be needed. This procedure is performed through the same skin incision as would be used for a joint replacement ( Fig. 16-154 ). The shoulder is approached through a subscapularis tenotomy ( Fig. 16-155 ), and adhesions in the humeroscapular motion interface are released ( Fig. 16-156 ). The subscapularis is released from the glenoid along with the attached subjacent anterior capsule ( Figs. 16-157 to 16-160 ) to allow a good range of passive motion ( Fig. 16-161 ). If there is a tendency for posterior instability, the capsular release is limited to the anterior aspect of the glenoid ( Fig. 16-162 ). Loose bodies, osteophytes, and interfering soft tissue are removed. The joint is thoroughly irrigated and gently manipulated to achieve the maximum possible range of passive motion, and the subscapularis is securely repaired ( Fig. 16-163 ). After surgery, a range of assisted motion exercises are immediately implemented. As with arthroscopic debridement, data on the effectiveness of this procedure are limited. We use it sparingly in cases of relatively early arthritis, especially in capsulorrhaphy arthropathy, where the anterior soft tissues have previously been tightened in the treatment of anterior instability (see Fig. 16-87 ).

Incision. The skin incision for the extended deltopectoral approach (dashed line) uses the mid-clavicle, the tip of the coracoid process, and the deltoid tuberosity of the midhumerus as landmarks. It is important that the incision avoid the axillary crease; otherwise, painful scarring might result.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:515.)

Subscapularis tenotomy approach. The subscapularis tendon is divided medial to its insertion on the lesser tuberosity.

Nerve-to-nerve release. All scar tissue in the humeroscapular motion interface (arrows) is released medially from the axillary nerve as it crosses the subscapularis, then under the coracoid, under the coracoacromial ligament, under the acromion, and finally under the deltoid to the axillary nerve posteriorly as it exits the quadrilateral space.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:517.)

Releasing the coracohumeral ligament. The coracohumeral ligament is released from the base of the coracoid process, allowing unrestricted gliding of the supraspinatus as well as the subscapularis.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:519.)

Releasing the subscapularis. A, The subscapularis is often tethered to the coracoid and glenoid via the capsule, limiting its excursion (arrow). B, The subscapularis is released circumferentially (red arrow), freeing it from the coracoid, the anterior glenohumeral capsule, the axillary nerve, and the coracoid muscles, allowing increased excursion (black arrow).

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:519.)

A 360-degree capsular release. A, The glenoid here is concentrically worn and the shoulder is tight. B, An extralabral release is therefore performed 360 degrees around the perimeter of the glenoid (red dashed line).

Posterior capsular release. If the posterior capsule is tight, it can be released under direct vision by rotating the inferior aspect of the retractor away from the glenoid and gently internally rotating the humerus.

The 40-50-60 rule for appropriate soft tissue tensioning is as follows: at least 40 degrees external rotation with a reapproximated subscapularis tendon (left), 50% posterior subluxation on the posterior drawer test (middle), and 60 degrees of internal rotation of the 90-degree abducted arm (right).

A, The preoperative axillary view shows posterior subluxation of the humeral head and posterior glenoid wear. B, The extralabral release (red dashed line) then includes only the anterior capsule. C, If the posterior instability is substantial, the release (red dashed line) stops at the inferior glenohumeral ligament.

Anatomic repair of the subscapularis tendon should allow at least 40 degrees of external rotation.

Synovectomy

The management of rheumatoid arthritis has been substantially improved through the use of disease-modifying agents (e.g., Plaquenil, cyclosporine, methotrexate, Cytoxan, Imuran, and Azulfidine) and biologics (e.g., Enbrel, Humira, Orencia, Remicade, and Rituxan). Before the availability of these medications, synovectomy and other nonprosthetic options were commonly used to remove inflammatory tissue from the glenohumeral joint. Currently, synovectomy is used primarily to manage refractory synovitis and bursitis in the absence of major joint surface damage ( Fig. 16-164 ).

The shoulder of a young man with rheumatoid arthritis and primary rheumatoid involvement of the subacromial-subdeltoid bursa. The rotator cuff was intact, and the glenohumeral joint had minimal involvement with rheumatoid synovitis. The patient had a full, minimally painful range of motion in the shoulder, with excellent shoulder strength. The hypertrophic bursitis did not respond to medical management, and the bursa was surgically excised.

Resection

Before prostheses were available, resection of the humeral head was used to manage arthritis and severe fractures. In general, comfort and function after resection arthroplasty are poor and so its current use is primarily for refractory infection or for failed arthroplasty without other means of reconstruction ( Figs. 16-165 to 16-167 ).

A shoulder with resection of the total shoulder humeral and glenoid components because of refractory infection. A, Anteroposterior view. B, Axillary view.

Resection for a failed arthroplasty.

A proximal humeral prosthetic replacement had previously been placed in an elderly woman with multiple-joint osteoarthritis. A, Her total knee arthroplasty became infected, and the infection spread to the proximal humeral prosthetic replacement. The shoulder region was brawny and erythematous, with a draining sinus on the anterolateral aspect of the arm. The region was debrided and the prosthesis and cement removed. B, Radiographic appearance of the joint after delayed primary closure. At follow-up, the patient had only mild pain, and the shoulder was stable because of fibrosis. She had active abduction of 65 degrees and external rotation of 10 degrees.

Arthrodesis

Considerations

Glenohumeral arthrodesis is usually reserved for attempts at salvaging septic arthritis or complex deficiencies of the joint surface associated with permanent loss of the cuff and deltoid. The best candidates for this procedure are shoulders that meet the following criteria: (1) permanent and severe weakness because of loss of cuff and deltoid function; (2) good scapular motors (e.g., trapezius, levator scapulae, pectoralis, serratus anterior, and rhomboids); and (3) sufficient residual glenoid and humeral bone stock to enable the fusion. Patients considering this procedure should have a strong motivation to succeed, minimal complaints of pain, and a good understanding of the following: (1) the potential complications of a shoulder fusion (including fracture of the humerus below the fusion); (2) the resultant limitation of internal and external rotation; and (3) the possible need for a second procedure to add bone graft to augment the fixation if the fusion does not “take” on the first attempt.

In the past, surgeons recommended fusing the shoulder in positions of abduction and flexion with the aim of optimizing function. However, such positions can be associated with substantial discomfort, largely related to the need to “wing” the scapula when the humerus is adducted to the resting position. To establish the limitations of function after shoulder fusion, we studied 12 shoulders that had undergone glenohumeral arthrodesis at least 2 years before the time of study. The mean humerothoracic elevation in the plus 90-degree (anterior sagittal) plane was 47 degrees, the mean elevation in the minus 90-degree (posterior sagittal) plane was 22 degrees, the mean humerothoracic external rotation was 9 degrees, and the mean internal rotation was 46 degrees. These ranges of motion were similar to the scapulothoracic motion measured in normal subjects. Only one patient could reach his hair without bending his neck forward, five could reach their perineum, six could reach their back pocket, seven could reach the opposite axilla, and ten could reach their side pocket. We conducted a second study of normal in vivo shoulder kinematics to predict the functions that would be allowed by various positions of glenohumeral arthrodesis. This indicated that activities of daily living could best be performed if the joint was fused in 15 degrees of flexion, 15 degrees of abduction, and 45 degrees of internal rotation. This low angle of elevation and relatively high degree of internal rotation facilitated sitting comfortably on a chair; lying flat in bed; and reaching the face, the opposite axilla, and the perineum. Thus our preferred position is the “15,15,45” combination described above, a position that minimizes protrusion of the shoulder blade posteriorly into the chair or bed when the arm is at the side. This position has the additional advantages of being easy to determine at surgery and needing only a sling for postoperative immobilization rather than a cast or brace. It is most important to avoid fusing the shoulder in neutral or external rotation because this position precludes reaching the mouth or perineum.

Many techniques have been described for shoulder arthrodesis. * When possible, our preferred method is an intra-articular fusion that preserves the deltoid, most of the rotator cuff, and most of the bone of the glenohumeral joint, allowing the potential for later conversion to a reverse shoulder arthroplasty. If necessary for stability, however, a neutralization plate can be contoured over the scapular spine and down the humerus, but this risks denervating the anterior and part of the lateral deltoid. A vascularized fibular graft has been recommended when there is bone deficiency.

* References .

Technique

The patient is placed in the beach chair position with the scapula in the prepared field and the arm draped free. The operative approach is through an anterior deltopectoral incision, with superior extension of the incision if plate fixation is used. We have used a low anterior axillary incision when cosmesis is a concern and intra-articular fusion is planned.

Any residual articular cartilage on the humerus or glenoid is curetted down to raw subchondral bone, as removing the subchondral bone weakens the construct and makes solid glenohumeral compression more difficult to achieve ( Figs. 16-168 and 16-169 ). The supraspinatus tendon is resected from between the humeral head and the acromion, and the undersurface of the acromion is stripped down to raw bone ( Fig. 16-170 ). The soft tissues are lifted from the anterior glenoid neck so that the subscapularis fossa can be palpated ( Fig. 16-171 ).

Humeral head curettage. The articular cartilage is removed from the head of the humerus without sacrificing subchondral bone. Access to the joint surface is achieved by external rotation.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:236.)

Glenoid curettage. The articular cartilage of the glenoid is removed with a curette without compromising the subchondral bone.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:237.)

Acromion curettage. The periosteum of the acromial undersurface is curetted without compromising the cortical bone.

Identifying the subscapularis fossa. The anterior aspect of the glenoid neck is palpated. This area will be the target for the compression screws.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:239.)

The humeral head is centered in the glenoid with the arm in 15 degrees of abduction, 15 degrees of flexion, and 45 degrees of internal rotation ( Fig. 16-172 ). It is temporarily fixed with three long 3.2-mm drill bits; these should exit the neck of the scapula anteriorly approximately 2 cm medial to the glenoid lip, where their tips can be palpated and controlled ( Figs. 16-173 and 16-174 ). When used in this manner, the known length of the drill bits can serve as depth gauges to determine the length of screws needed. The position of the arm is checked by making sure that the hand can reach the mouth, the anterior perineum, and the contralateral axilla. The 3.2-mm drill bits are sequentially replaced by fully threaded 6.5-mm cancellous screws with washers ( Figs. 16-175 and 16-176 ). Because the humeral head is softer than the glenoid, compression can usually be achieved without formally lagging the screw or needing to use a smooth shank.

For many patients, the most comfortable position of fusion is that of 0 degrees of flexion, 0 degrees of abduction, and 60 degrees of internal rotation. This position allows the scapula to sit in its normal position on the chest wall while the arm is at the side.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:239.)

While the humeral head is held reduced in the glenoid fossa in its proper position, a drill bit is passed through a stab incision then through the deltoid, the proximal humerus, and the glenoid, before exiting anteriorly from the neck.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:240.)

Subsequent drill placement. Two additional drill bits are placed parallel to the first, equally spaced across the glenohumeral joint. The position and orientation of the humerus in relation to the glenoid is checked again.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:241.)

Screw placement. The drill bits are sequentially replaced with 6.0-mm fully threaded cancellous screws with washers.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:242.)

Screw length. Each screw should just penetrate the subscapularis fossa at the base of the glenoid neck.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:243.)

An iliac crest bone autograft is fashioned to fit between the humeral head and the acromion; it rests in the position normally occupied by the supraspinatus tendon ( Figs. 16-177 to 16-179 ). Interposition of the iliac crest graft maximizes humeroscapular contact by preserving the normal concave-convex glenohumeral relationships while allowing stabilizing contact between the head, the graft, and the acromion. If the humeral head is moved upward to make contact with the acromion without a graft, the glenohumeral contact area for fusion gets reduced. The graft is held in position by another screw placed from the acromion through the graft and out through the anteromedial aspect of the humeral neck ( Figs. 16-180 and 16-181 ). Additional bone graft is added around the fusion area to optimize healing.

Acromiohumeral (AH) distance. After the supraspinatus tendon has been resected, the distance between the humeral head and the acromion is measured.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:243.)

Graft harvest. A segment of graft measuring 20 × 20 × 8 mm is harvested from the iliac crest.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:244.)

Graft placement. The graft is placed between the humeral head and the acromion in the area normally occupied by the supraspinatus tendon. This graft increases the quality of the fixation while helping maintain the position of the humeral head in the glenoid concavity.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:245.)

Graft fixation. A fourth screw is passed through the acromion, the graft, and out the firm bone at the humeral neck.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:247.)

Cancellous grafting. Cancellous bone graft is added across the area of glenohumeral arthrodesis.

(From Matsen FA III, Lippitt SB. Shoulder Surgery: Principles and Procedures. Philadelphia: Saunders; 2004:247.)

Depending on the circumstances, a neutralization plate (usually an 8- to 12-hole dynamic compression plate or pelvic reconstruction plate) may be used ( Fig. 16-182 ). If so, several points need to be emphasized. The plate needs a bend of about 90 degrees at the acromion and often an internal rotation twist of about 45 degrees to fit on the anterior of the humerus. The strongest fixation for the plate on the scapula is obtained by a screw down the base of the spine of the scapula just medial to the spinoglenoid notch. The arm is protected in a sling until the fusion is clinically and radiographically healed. When the fusion is solid, function and comfort can be enhanced by strengthening the periscapular musculature.

Glenohumeral and acromiohumeral arthrodesis performed using a contoured iliac crest bone graft inserted between the acromion and the humeral head. The arthrodesis is stabilized securely with the following components: three washered, fully threaded cancellous humeroglenoid screws; one fully threaded cancellous screw through the acromion, graft, and humeral head; and a contoured reconstruction plate.

Complications of shoulder arthrodesis include nonunion, infection, malposition, prominence of the internal fixation plates, and fracture. Nonunion can be treated by freshening the arthrodesis site, repeat fixation, and bone grafting. It can sometimes be difficult to be sure from radiographs whether or not the fusion is solid; in such cases a reexploration may be helpful in evaluating the completeness of the fusion and the security of the internal fixation. Infection is treated by incision, drainage, and antibiotics, attempting to maintain the hardware stabilizing the fusion. Malposition is most commonly in excessive flexion, abduction, or external rotation. It is often preferable to manage malposition by humeral osteotomy ( Fig. 16-183 ), rather than by taking down a solid fusion and attempting to reposition it. Care must be taken in removing prominent hardware unless the fusion is absolutely solid. Humeral shaft fracture is a particular risk because the fused shoulder lacks the normal shoulder’s ability to absorb load without damage.

Subtuberous humeral osteotomy performed for a shoulder that was fused in excessive abduction, excessive flexion, and malrotation. A, Internal fixation. B, After internal fixation has been removed.

Arthroplasty

Considerations

Under optimal circumstances, glenohumeral arthroplasty can be a powerful approach for reconstructing an arthritic shoulder. In considering the advisability of a shoulder arthroplasty and the selection of a specific procedure, it is important to consider the four Ps.

• 1.
  

  Is the problem (diagnosis and associated aspects of the shoulder) one that can be well managed with arthroplasty? Are the essential bone, deltoid, cuff, nerve, and skin tissues in sufficiently good condition for a safe and effective arthroplasty? Is the severity of the problem typical of patients presenting for shoulder arthroplasty ( Fig. 16-184 )?

  
  

  
  

  
  

  

  
  

  
  

  Frequency distribution of the number of Simple Shoulder Test functions that a sample of patients was able to perform immediately prior to shoulder arthroplasty. We use this chart to help the patient consider the question, “When is my arthritic shoulder bad enough to justify a joint replacement?” As shown by this graph, the great majority of these patients were able to perform less than half of the 12 functions.

  
  
  
  
• 2.
  

  Is the patient informed and in sufficiently good physical, social, and emotional health to succeed with the procedure and its postsurgical rehabilitation? Comorbidities, level of education, type of insurance, age, sex, and the patient’s overall well-being have all been shown to influence the outcome of the arthroplasty.

  
  
• 3.
  

  Is the physician sufficiently experienced in shoulder reconstruction to optimize the chance of a good outcome? Many shoulder arthroplasties are performed by surgeons who perform only a small number of these cases each year, yet case volume has a strong influence on the outcome of the surgery. As we say, “The surgeon is the method,” and “Experience is the great teacher.”

  
  
• 4.
  

  Is the procedure appropriate for the problem, patient, and physician? Among the variations of shoulder arthroplasty available, which is the best fit for the shoulder, the patient, and the surgeon?

Types of Arthroplasty

There are four basic types of shoulder arthroplasty: the humeral hemiarthroplasty, the ream and run arthroplasty (humeral hemiarthroplasty with a nonprosthetic glenoid arthroplasty), the anatomic total shoulder arthroplasty (humeral hemiarthroplasty with a prosthetic glenoid arthroplasty), and the reverse total shoulder arthroplasty.

Prosthetic humeral hemiarthroplasty is considered under the following circumstances: (1) when the glenoid articular surface is intact (as in avascular necrosis before collapse of the humeral head and before secondary destruction of the glenoid surface); (2) when there is insufficient joint volume or glenoid bone stock to allow for secure placement of a glenoid component; (3) in cases of rotator CTA when the humeral head is stabilized by an intact coracoacromial arch (see Fig. 16-110 ) and active elevation exceeds 90 degrees ; and (4) in cases where concern about infection discourages the use of a glenoid component. In glenohumeral arthritis—that is, when both the humeral and glenoid articular surfaces are involved—a hemiarthroplasty alone may be insufficient treatment. There are two types of humeral hemiarthroplasty implants: a humeral head prosthesis fixed with a stem inserted down the medullary canal of the humerus ( Fig. 16-185 ) and a partial or complete resurfacing prosthesis mounted on the retained biologic humeral head ( Fig. 16-186 ).

Humeral head prosthesis fixed with a stem inserted down into the humeral medullary canal.

Complete resurfacing head prosthesis mounted on the retained biologic humeral head.

Ream and run arthroplasty (humeral hemiarthroplasty with a nonprosthetic glenoid arthroplasty) is considered for the treatment of glenohumeral arthritis when the patient, after being informed, wishes to avoid the potential risks and activity restrictions associated with a prosthetic glenoid component. Initially there was interest in biologic resurfacing of the glenoid with capsule or cadaveric meniscus ( Fig. 16-187 ) as a way to avoid the risks of prosthetic glenoid component failure; however, recent experience with this approach has not been encouraging. The ream and run procedure is a glenohumeral arthroplasty in which a humeral hemiarthroplasty is combined with conservative reaming of the glenoid to a single concentric concavity without substantially modifying glenoid version and without the use of biologic interposition. Because the ream and run procedure modifies both the humeral and glenoid articular surfaces, it is a glenohumeral arthroplasty; this should not be confused with a hemiarthroplasty in which only the humeral side of the joint is addressed. We refer to it as a radically conservative procedure because it involves the removal of less glenoid bone than would be required for the insertion of a glenoid component.

Biologic glenoid resurfacing with a knee meniscal allograft.

In the anatomic total shoulder arthroplasty , a humeral hemiarthroplasty is combined with a prosthetic glenoid component. The total shoulder arthroplasty is the most commonly used approach to glenohumeral arthritis when the rotator cuff is intact and when sufficient glenoid bone is available for fixation of the glenoid prosthesis.

In the reverse total shoulder arthroplasty , the positions of the ball and socket are reversed from the anatomic arrangement. This type of prosthesis is used when the arthritic shoulder demonstrates instability that cannot be managed with an anatomic prosthesis or when the shoulder is “pseudoparalytic,” meaning that the shoulder cannot be actively elevated to 90 degrees despite a good range of passive motion and intact deltoid function. Reverse total shoulder arthroplasty is used to manage rotator CTA and anterosuperior escape after a failed attempt at rotator cuff repair (see Figs. 16-109 to 16-111 and 16-115 ). Reverse arthroplasty is also used to manage comminuted proximal humeral fractures in the osteopenic bone of older individuals, massive cuff tears without arthritis, and failed anatomic arthroplasty with instability or pseudoparalysis ( Fig. 16-188 ).

Failed anatomic prosthesis for a fracture with pseudoparalysis. A, Anteroposterior view showing superior placement of the humeral prosthesis, superior subluxation of the humeral head, and an absent greater tuberosity. B, Because of the high position of the stem, the humeral prosthesis had to be removed at the time of conversion to a reverse total shoulder arthroplasty.

Mechanics of Anatomic Arthroplasty

Four basic mechanical characteristics are essential to shoulder function: mobility, stability, strength, and smoothness. Commonly, each of these characteristics is compromised in an arthritic shoulder, and each can potentially be improved by shoulder arthroplasty. The approach to glenohumeral arthritis is guided by an understanding of these elements necessary for optimal shoulder mechanics. Restoration of glenohumeral mobility and stability is the priority rather than trying to recreate “normal anatomy.” In performing glenohumeral reconstruction it is often necessary to modify the humeral head size, thickness, and eccentricity to achieve the desired joint mechanics while preserving glenoid and humeral bone stock. Thus templating systems or patient-specific instrumentation systems based on a preconceived “normal” shoulder are less helpful than learning to use techniques, such as those involving eccentric humeral heads, humeral heads of different thickness, and rotator interval plication to manage the wide range of arthritic pathologies.

Mobility

The requisites for a normal range of glenohumeral motion include normal capsular laxity, appropriately sized and shaped concentric articular surfaces, and the absence of osteophytes or other unwanted sources of contact between the proximal humerus and the lateral scapula.

Capsular Laxity.

In normal shoulders ample capsular laxity allows the full range of rotation at the glenohumeral joint. The glenohumeral capsule normally remains lax through most of the functional range of motion. As the joint approaches the limit of its range, the tension in the capsule and its ligaments increases sharply, checking the range of motion ( Fig. 16-189 ). However, in most conditions that require shoulder arthroplasty, the capsule and ligaments are contracted; this prematurely limits the range of motion and increases the joint pressure at the limits of motion ( Fig. 16-190 ). In 1994 we introduced the term “stuffing” referring to additional tightening of the capsule that results from the insertion of prosthetic components that take up more space than that afforded by the available joint volume ( Fig. 16-191 ). Unless capsular releases ( Figs. 16-192 and 16-193 ) sufficient to accommodate this additional volume have been performed, the joint becomes “overstuffed,” limiting joint motion ( Fig. 16-194 ), with greater torque (muscle force) required to move the arm ( Fig. 16-195 ). Cadaver studies have indicated that less than 10 mm of overstuffing can reduce normal capsular laxity by as much as 50% ( Fig. 16-196 ). Overstuffing also causes obligate translation of the humeral head on the glenoid, resulting in eccentric glenoid loading ( Table 16-3 ); for example, the compressive load increases and forced posterior translation occurs when external rotation is attempted against a tight anterior capsule, accounting for the pathology common seen in capsulorrhaphy arthropathy (see Fig. 16-88 ; Figs. 16-197 and 16-198 ).

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